P6683Management of lentigo maligna: A surgical conundrum

Navara Anjum, St. Mary’s Hospital, Portsmouth, United Kingdom; Peter Gonda,Queen Alexandra Hospital, Portsmouth, United Kingdom; Philippa Shepherd, St.Mary’s Hospital, Portsmouth, United Kingdom; Stephen Keohane, St. Mary’sHospital, Portsmouth, United Kingdom

Lentigo maligna (LM) is a common skin malignancy and is best treated by surgicalexcision because of the risk of subclinical microinvasion. The recommendedsurgical margin is 5 mm; however, these tumors can often have indistinct margins,therefore excision via Mohs micrographic surgery is preferential. Variety existswhen processing specimens during slow Mohs with some operators using frozensections (FS) whilst others preferring paraffin-embedded sections (PES). Thetechnique used by our department involves initially removing the entire pigmentedlesion with 2-mmmargins. By sampling the whole clinically visible lesion, we aim toreduce the risk of missing LM melanomawhich can occur if only part of the lesion isbiopsied. The second stage comprises standard Mohs technique by removing a discof tissue around the original defect with a further 2-mm margin to include both thedeep and superficial aspects using a 458 angle. These specimens are then flattened,paraffin embedded, and horizontal sections are cut which allows both the deep andperipheral margins to be analyzed. Alternate sections are stained for hematoxyli-neeosin (H&E) followed by immunohistochemistry (IHC). Subsequent stagedsections are then guided by histology. In our experience, analysis of LM is superiorwhen using PES as opposed to FS. Considerable artefact can occur with FS and IHCcan be more difficult to interpret. LM is a difficult tumor to diagnose histologically,and this together with the difficulties experienced with FS can result in incompletetumor excision especially when assessing the subtle peripheral changes. Thistechnique can be demonstrated by a patient referred for slow Mohs micrographicsurgery of LM at the left nasal alar. PES were analyzed initially using H&E. Duringexamination of the second stage, 2 seemingly separate suspicious areas were notedwith H&E, but IHC revealed the true extent of the tumor to be far greater thaninitially delineated, with most of the inferior-anterior margin involved. This casehighlights the surgical conundrum posed by LM and emphasises the need for IHC.H&E stain alone may underestimate the true extent of the lesion especially in laterstages when peripheral changes maybe subtle thus increasing the risk of incompleteexcision. We advocate the removal of the whole clinically visible lesion initially toreduce the risk of sampling error and recommend the use of PES to allow for a moreaccurate histologic analysis of a tumor that poses histologic difficulties.

APRIL 20

cial support: None identified.

Commer

P6692Medial eyebrow defects: Reconstruction with whole eyebrow subcutane-ous island pedicle

Waseem Bakkour, MD, Salford Royal NHS Foundation Trust, Salford, UnitedKingdom; Vindy Ghura, MBBS, Salford Royal NHS Foundation Trust, Salford,United Kingdom

The subcutaneous island pedicle flap is commonly used by dermatologic surgeonsto repair defects of the upper cutaneous lip, cheek, nose, and forehead. There are alimited number of reports that describe the use of this flap to repair eyebrow defectswhere authors have described the flap for repair of lateral and central eyebrowdefects rather than medial ones. Removal of medium to large skin cancers located inthe medial eyebrow area can result in defects that include the medial eyebrow head.Repairing such defects can be challenging. The eyebrow is an aesthetically key site,helping to frame the central forehead. Several points must be considered whenrepairing eyebrow defects, including maintaining the symmetry of both eyebrows,and maintaining equal length where possible in addition to maintaining adequatevascular supply and minimizing hair follicle destruction. Many methods have beendescribed eachwith its advantages and disadvantages. Full thickness skin grafts fromhair-bearing scalp have been used; however, hair growth in abnormal direction andthe mismatch of any accompanying glabrous skin limit their cosmetic feasibility. Thebilateral advancement flap, which has been used for defects within the eyebrow,does not always yield the best cosmetic result as the medial eyebrow head tends tobe displaced laterally. Again, an O to T flapwill be difficult to execute here for similarreasons, and it is likely to shorten and elevate the eyebrow. Vertical closure is onlypossible for small defects in this area.We report our experiencewith using the islandpedicle flap for this uncommon location. Whenmedial eyebrow defects that includethe medial head result, the whole residual lateral eyebrow can be advanced mediallyas an island pedicle with central subflap vascular pedicle to recreate the medialhead. This enables good alignment of the medial eyebrow head with the contralat-eral eyebrow, achieving symmetry with minimal shortening of the eyebrow.

cial support: None identified.

Commer

13

P6101Multiple piloleiomyoma treated with suction-assisted cartilage shaver

Hyo-Jin Kim, MD, Department of Dermatology, Busan Paik Hospital, College ofMedicine, Inje University, Busan, South Korea; In-Ho Park, MD, Department ofDermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan,South Korea; Jai-Kyoung Koh, MD, Department of Dermatology, Haeundae Paik,College of Medicine, Inje University, Busan, South Korea; Jeong-Nan Kang, MD,Department of Dermatology, Busan Paik Hospital, College of Medicine, InjeUniversity, Busan, South Korea; Jong-Keun Seo, MD, Department of Dermatology,Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea;Jung-Eun Seol, MD, Department of Dermatology, Busan Paik Hospital, College ofMedicine, Inje University, Busan, South Korea; Young-Suk Lee, Department ofDermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan,South Korea

Piloleiomyoma is a benign neoplasm arising from the arrector pili muscle in the skin.It occurs as linear, or dermatomal arrangements of firm, red to brown intradermalnodules, which are fixed to the skin, but not to the deeper tissues. Although varioustreatments had been tried, they showed limited success and remained severalcomplications. A 21-year-old man presented with 3-year history of multiple,erythematous and firm 4-mm to 3-cm sized nodules on the chest. Histopathologicexaminations were compatible with piloleiomyoma. The lesions were removed bydermal shaving method with suction-assisted cartilage shaver. Each lesions becamemarkedly flattened. The method has the advantage of a short operation time, rapidrecovery for returning to daily activities, and less subjective pain compared withclass surgical methods. There has been no adverse events or recurrence.

cial support: None identified.

Commer

P7013Prolonged dorsal nasal flap with superiorly based nasolabial flap for largenasal tip defects: One-stage reconstruction

Pedro Redondo, PhD, MD, University Clinic of Navarra, Pamplona, Spain; AnaGim�enez-Azc�arate, MD, University Clinic of Navarra, Pamplona, Spain; IsabelBernad, MD, University Clinic of Navarra, Pamplona, Spain; Isabel Irarrazaval,MD, University Clinic of Navarra, Pamplona, Spain; Miguel Lera, MD, UniversityClinic of Navarra, Pamplona, Spain

Background: The typical reconstructive options for the nasal tip and columella arethe paramedian forehead flap and the dorsal nasal flap. Other alternatives are adelayed open-pedicle melolabial transposition flap, and bilobed or trilobed flaps.Most clinicians assume that it is almost impossible to repair an entire nasal tip defectin a 1-stage operation.

Objective: This paper will describe the first report of repairing a large nasal tipdefects with a combination of dorsal nasal flap and superiorly based nasolabial flap.The superiorly based nasolabial flap is designed with a length adapted in eachparticular case to the morphology of the defect.

Methods: This is a report of 2 similar reconstructive cases after Mohs micrographicsurgery requiring the repair of large defects of the nasal tip and columella.

Results: To the best of our knowledge, this is the first report of repairing a large nasaltip defect with a combination of dorsal nasal flap and superiorly based nasolabialflap. The paper describes the operative details and discusses the features of this flap.These cases demonstrate the feasibility of this technique.

Conclusion: The prolonged dorsal nasal flap with superiorly based nasolabial flapprovides an excellent aesthetic and functional outcome for many defects of the nasaltip. It is a nasolabial prolongation of the Rieger/dorsal nasal flap, with a simpledesign and easier execution. We consider it a robust and reliable reconstructiveoption for large defects of the nasal tip and columella.

cial support: None identified.

Commer

J AM ACAD DERMATOL AB221